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3AN JOA�U2A7 Ld(_P,L'• HA�ar Z•c- D2STF22G'T <br /> ,,// J <br /> CNDbRC p TANK DISPOSITION TRACKING Rr=M r <br /> <zxzrsxz*zzrzxttxrxxrzzxzxxzxxxzzxxxtzxzxzzxxxxzx:xzxxxzxtxrzxtxxrtztttzzrztrxxxxr <br /> -V 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> .xed with its site identification number. The Tracking Sheet is to be returned to San <br /> cquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> yc_ing facility. The hold * o permit with numnP <br /> ersuring that this form is r-omolet .o + bied and rete ped ow is responsible for <br /> FACILITY NAhM: GUARDINO & CRAWFORD Co, <br /> FACILITY ADDRESS: 517 W. Fremont Street ` <br /> ort <br /> TAMC ID ENVIRONMENTAL HEAL;; <br /> xrrxxzxzxxxxxxzzxtzxxxxxzxzxzr:=zxxz=x==zxrzzxzzxxxzxzxx xtxxxxx tx xxxxxtx z:�'t`#5ti`f�*Ttdr��E�''yj�x <br /> SFXTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Stockton Contracting Group; Inc: <br /> 1000 N. non Street <br /> Address.: - Union Stkn. Ca. -�- - -- - -- <br /> Zip:• 95205 <br /> P21one0: (2(9) 462-5082 <br /> Telephone: ( 209 462-5082 Date Tank Removed <br /> zxzxzr*x*xxtxxxxzxxxxxxxzt:ztxzxxtztzxxztzxzxzxzzzx*xzxztzxxtzxxzxzxxxzxxxxyrxxzxxztxxrxrzxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Stockton Contracting Group <br /> Address: 1000 N. Union Street Stkn: Ca. <br /> Zip: 95205 <br /> Phoneii: (20-97-4-6-2-5582 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontamina an a owed manner ma be re lat <br /> 1' 9u g�partment of Health Services. <br /> zttxxxxtzxxxzxx:xzxxx xxxxzxzx:zxtzxlzxxx�xxEzt�xzzTITLE <br /> zxxzxirxzxxxzzxxzxzxxxxxxxxtxxxxxzxxx <br /> SECTION 9 - To be fil ed out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. - <br /> Facility Name k1porA'(i <br /> Address: 22-� °�'��7f�t�amtlt Zip: 9�761 <br /> �honeY: F7��{-) 48R-$ooa <br /> Date Tank Received:�•�!� <br /> xxxrxxxxxxxrxxxzxrxxrxxxzxzxxx AUTHORIZED <br /> StIGNATL)RE AND <br /> TITxxxxxtxxxxxrxzxxzrxxxxxxxrxxxxx:r <br /> EH 23 019 11/88 <br /> �TrING INSTRUMONS: FOLD :N HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAMC PRCGRAM <br /> P. D. BOX 2009 <br /> STOCCTON, CA 95202 <br />